Following on from last week’s debut, it’s time to turn focus to the latest line of injuries with Dan Agger’s leg injury, Samir Nasri’s hamstring and Stephen Ireland’s arm all taking place on my virtual treatment table. I’ll also take time to assess those already under treatment, with Bacary Sagna and Jack Wilshere closing in on a return to action…

New Arrivals

Daniel Agger
The injury to Daniel Agger occurred as the Dane and team-mate Glen Johnson both attempted to thwart the gazelle-like advances of United’s Antonio Valencia, who swiftly and elusively skips between the pair, leaving the two Liverpool players on collision course. Agger, with left leg at full stretch slides in, just as Johnson bears down with his own challenge, connecting with Agger’s knee, just below the joint line with what can be described as a “valgus force”, a specifically angled and levered pressure that, with pace and force, places great stress on the Medial Collateral Ligament (MCL).

Initially we see Agger attempt to get to his feet, where he is unable to put any weight through the affected knee. A further diagnostic clue unfolds as the camera cuts to the physio treating Agger on the ground. We witness the physio applying a valgus and varus stress test to the knee. Immediately after the test, presumably fearing Collateral Ligament damage, the physio calls for a stretcher.

As Agger is carried from the field we are able to witness the stricken player holding his leg on the inside of his thigh and the outside of his ankle, as though applying his own varus pressure, a movement that would minimise MCL stretching and, presumably, ease the pain. It was therefore no surprise to see early indications of a suspected MCL strain. Subsequent reports from Anfield suggest the injury is not as serious as anticipated and diagnose a ‘significant bone bruise with no ligament damage.’

A contusion or bruise is a term often applied to soft-tissue damage. When it is used for bone it usually describes a crush injury to the bone. The hard outer surface compacts into the softer, spongy, shock absorbing inner aspect of the bone. Some medics refer to this type of injury as a type of fracture and one would also expect some soft-tissue damage. Not knowing the depth of the contusion or the extent the injury renders time-scale predictions tricky. “Significant bone bruising” could well render the bone susceptible to fracture and Agger will be under constant review from an Orthopaedic specialist to ensure he returns with minimal risk of re-injury.

Taking Liverpool at their word I feel it would be optimistic for Agger to be in contention for either Norwich or Stoke, although if the injury turns out to be a minor bone contusion and he responds well to treatment, Stoke might well be a possibility.

Samir Nasri
In the 33rd minute of the match between Manchester City and Real Madrid, Samir Nasri, during a rare foray into Real Madrid’s penalty area, can be observed accelerating into space, only to be blindsided and unceremoniously dumped to the ground with a ‘tank’ of a shoulder charge from the Real defender. The blow was harsh and unexpected and curtailed Nasri in full flight. Less than a minute later Nasri can be seen holding the back of his thigh directly over the muscle belly of Biceps Femoris, one of the hamstring group. Thirty seconds later he falls to the ground, again clutching his hamstring in the same area. He then leaves the field with a pronounced gait.

From where Nasri was holding his leg we may infer that he incurred no tendon damage (although tests would be undertaken to confirm this) as he clutched the back of his upper thigh right in the middle of the muscle belly throughout. This is one of the more common areas for hamstrings to tear and given the voluminous blood supply to the muscle, recovery should be much shorter than if the tendons were involved. Personally I feel that Nasri suffered a mild to moderate grade 1 to 2 hamstring strain, meaning only a small cross sectional area of muscle would be involved, with major disruption to the fibres unlikely.

Every patient rehabilitates at a different speed, and transition from one phase to the next will depend upon the severity of the injury and the response to treatment. Two factors can be used to predict the length of time needed for athletes to return to full function from a hamstring strain; the amount of time it takes a player to walk without pain and any previous hamstring injuries suffered, information that I’m not privy to. However, on balance, my instinct is that we could see Nasri grace the City first team approximately three weeks from the date of injury. The Fulham match may come too soon, then, a more realistic return could be when Sunderland roll up to the Etihad on October 6.

Stephen Ireland
The Aston Villa midfielder was taken off at half time at St Mary’s with a suspected broken arm. If x-rays confirm this the length of any absence will depend upon several factors; the category of fracture suffered, if the fracture was complete or in-complete, how much of the bone shaft was affected, the shape or the line of fracture and if the fracture was displaced or in-displaced – do the bone ends still end in opposition or will some type of ‘reduction’ need to be administered. In other words, the severity and type of fracture will dictate likely return scenarios.

From discussions with a physiotherapist who has worked in professional football for a number of years, we can summarise that the extent of the damage will dictate the best line of treatment. If displaced, surgery may be advocated to approximate the bones. If notdisplaced, but x-rays still reveal a full fracture, then a period of immobilisation, usually four weeks, in a plaster cast will be required. Even post four weeks, again, depending on the severity, most clubs will see a further two weeks of healing as necessary to avoid the risk of re-fracture. If not a full fracture, we should still anticipate four weeks as a minimum absence. Again, Ireland will be under constant review by orthopaedic specialists to ensure that the player returns with minimal risk of further injury, so, my gut instinct is three weeks may still be too soon despite being possible.

Under Treatment

Bacary Sagna
On the September 21 Arsenal updated Bacary Sagna’s progress indicating that The Frenchman is one week away from full training.

Arsene Wenger, correctly, has a tradition of nurturing long term injured players back slowly and delicately and when you consider that this is the second fracture of the Fibula that Sagna has incurred in the last eight months, caution is understandable. With this in mind, when full training is resumed on the September 28, it is logical to assume that the medical staff would want to monitor full training for any reactions or latent deficits for a further 10 to 14 days before a return to competitive action would be considered. Factor in performance related fitness and match sharpness and, barring any set-backs, expect him to be physically ready to play some part when Arsenal roll up at Norwich, after the international break, on October 20.

It has to be noted that his rehabilitation, this time, will have taken close to six months, whereas his previous Fibula fracture took four months to heal. He won’t be rushed back prematurely. He is also now 29-years-old and this type of serious injury can leave psychological and physiological scars. An accumulation of injuries can potentially have significant consequences and often leaves its mark mechanically. There is also Carl Jenkinson’s almost match by match improvement to consider. The ex-Charlton starlet is the future of Arsenal, playing well in the present. He is staking a claim and has already laid sturdy foundations. Add into the mix the resolve shown by the Arsenal rearguard this season and we can see quite a conundrum building for “professor” Wenger.

Jack Wilshere
Arsenal were further buoyed with the news of the return to full training of another long-term absentee, Jack Wilshere. A stress fracture to the ankle, hampered by a string of aggravations and set-backs, caused him to miss the previous 14 months.

His physical rehabilitation is now nearing completion and the next stage is to monitor his reactions to full training, which he resumed on the September 20 and taking into consideration the length of absence and Wenger’s penchant for patience and caution with long term injury casualties, it is safe to assume that he will be monitored for reactions before any type of competitive match would be considered. Reports today suggested that Wilshere could feature in Monday’s U21 encounter with West Brom. That may well come too soon – reports also suggest that the Gunners are looking to another U21 fixture, the meeting with Reading on October 8.

You can bet that Wilshere won’t be rushed. All things considered he is still three, probably four weeks away from a first team recall and barring set-backs he should be in contention around the time that Arsenal entertain QPR at the Emirates on October 27.

* Please note, while “From the Physio” offers a unique insight into the injuries that are concerning Fantasy Football managers, such a piece must come with a hefty disclaimer. We might be offering an expert’s view of such injuries but, as with just a remote assessment to go on, the views expressed here should not be taken as gospel or with any certainty. They are, however, hopefully of great interest and arm Fantasy managers with more information to help make their own judgements.